Unity Farm Journal - 5th Week of July 2014

The great thing about running a farm is that every day is filled with the unexpected.

Sunny, our new baby alpaca did not consume her first meal of mother’s milk in time to receive the antibodies that are necessary to keep her healthy.   She was not gaining weight.   We had only one choice - a transfusion of alpaca plasma containing IgG (about $150).     We drove to Tufts Veterinary School and picked up 500cc of plasma.   There are two ways to transfuse a baby alpaca - jugular vein IV or peritoneal infusion.   Inserting an IV in a baby alpaca is like wrestling an alligator.  We chose the peritoneal approach which required shaving her belly, a bit of anesthetic, and a quick puncture to insert a blunt tube for infusion.   After 10 minutes of infusion she was back to the paddock.   Since the infusion, she has gained weight, had boundless energy and is on her way to becoming a healthy adult alpaca.   Here are before and after pictures, illustrating the use of our kitchen as an operating room.

Over the weekend, I put on my bee suit to help my wife and daughter inspect the hives and move heavy honey filled frames.   As I walked past the cider house I noticed a grey guinea fowl that had disappeared in the forest about a month ago.  We were convinced that a coyote had taken her.   Behind her were 17 babies that she successfully raised in the forest and now was leading back to the coop.   Other guineas in the flock do not seem to recognize their own young species and tend to harass babies, sometimes to the point of killing them.  I ran to the hives and asked for my daughter’s help.   Together we wrangled all 17 babies into a large farming bucket and placed them in a 100 degree F brooder where they ate, drank, and warmed up after their travel through wet grass.    Today they are happy and healthy and we’ll move them to one of the mini-coops on August 16.   Mom is a little disturbed that we took her babies away, but she’s returned to the coop and settled in with the other guineas.    We still have two nests in the forest and if they are successful, we’ll have over 100 guineas on the farm.     We’ve already put up notices at local farm stands offering guinea chicks for sale.

All of this guinea mania required a bit of new construction.    I built another mini coop in the larger coop, so now we have 5 areas for poultry.

brooder - 3 levels, can hold 100 chicks
mini-coop #1 - can hold 5 “teenagers”
mini-coop #2 - can hold 10 “pre-teens”
coop side #1 - can hold 25 adults
coop side #2 - can hold 25 adults

Today we have 17 chicks, 3 teens, 9 pre-teens, and 27 adults.   We’re going to run out of space if they forest nests are successful.

The hoop house continues to produce massive quantities of cucumbers, tomatoes, chard, squash, and eggplant.   One of my favorite vegetables is Japanese pumpkin (Kabocha) and I’ll harvest 25 pounds of it this weekend.

All is well on the farm as Fall approaches.   The ducks are eating worms in the compost pile and the joyful chaos continues.

Real Time Big Data Analytics for Clinical Care

Over the summer, I’ve given many lectures about SMAC - social media, mobile, analytics and cloud computing.

The most popular analytics topics are business intelligence, big data, and novel data visualizations.

Recently, Dr. Chris Longhurst, chief medical information officer at Lucile Packard Children's Hospital, and colleagues wrote an article in the Big Data Issue of Health Affairs, that suggests a very practical approach for enabling real time analytics within an EHR.   They call it the Green Button.

The Blue Button is for patient view/download/transmit of medical records.

The Green Button is for instant access to outcomes, cost, and risk information for patients that match a given profile.

Here’s a personal example.

When my wife was diagnosed with Stage IIIA Breast Cancer in December of 2011, the biomarkers of the tumor were HER2 -, Estrogen +, Progesterone +.    Imagine that while in her record, a Green Button enabled access to the de-identified records of all 50 year old, Asian females with similar tumors and showed the treatment protocol used, the side effects, the cure rate, the cost, and the complications.

Although not completely scientific, such an approach does not identify causality, it does demonstrate experience and standard practices in the community.   The Green Button idea is foundational to the learning healthcare system we’re all trying to build.

We do need to be careful.   Here’s one example from our work with I2B2/Shrine.

Did you know that the average human white blood cell count is 5 at noon but 13 at 3am?

Scientifically we know that white count does not vary with circadian rhythm.   However, who has a white blood cell count drawn at 3am?  Sick people.

You cannot conclude that white count varies over the course of a day because the data has confounding complexities.

However, there is an interesting possible conclusion.   People who get white counts drawn at 3am, get blood cultures at 4am, and antibiotics at 5am.   We can suggest that if you order a white count at 3am then you want to order a blood culture and antibiotics at the same time, since you’ll end up doing it anyway.

The Green button idea is to present valuable historical observational data at the point of care.

I2B2 is a great tool for clinical research and clinical trial enrollment, but imperfect for point of care advice.

How might the Green button be developed?

Emerging companies like QPID are creating new tools that summarize structured and unstructured data into unique visualizations.   I'm on their Advisory Board.

The BIDMC experience with care management using a third party registry populated via the state HIE also provides promise.

I look forward to experimenting with the Green Button concept - another item on my to do list for the next year.

There’s More to ePrescribing Standards Than You Think

In followup to my guest post from Dr. Marvin Harper about e-Prescribing gaps, John Klimek, R.Ph., Senior VP, Standards and Information Technology, NCPDP wrote the following helpful guest post:

The National Council for Prescription Drug Programs (NCPDP) leaders and members read with interest the guest post from Dr. Marvin Harper, CMIO at Boston Children's Hospital, entitled “Limitations of e-Prescribing Standards.” Dr. Harper’s thoughtful post brings a critical issue to light: the need for increased industry awareness and adoption of the full functionality that already exists in ePrescribing standards – going beyond the core requirements of Meaningful Use. ePrescribing is important in improving both the quality of patient care and patient safety. It provides a key point of communication between care providers, and can help improve patient compliance with treatment regimens.

ePrescribing Standards: What’s Covered

Three standards are used in ePrescribing – the NCPDP SCRIPT Standard and the NCPDP Formulary and Benefit Standard, and the ASC X12 Standards for Electronic Data Interchange Technical Report 3 - Health Care Eligibility Benefit Inquiry and Response - 270/271. The eligibility transaction is typically exchanged prior to the patient encounter and can supply the prescriber system with information about the patient’s pharmacy benefit, including the payer, member ID, formulary and coverage pointers, and other details. The Formulary and Benefit Standard provides a means for pharmacy benefit payers to communicate formulary and benefit information to prescribers via technology vendor systems at the point of prescribing. The file exchange includes information on formulary status, alternative drugs, co-pays and other information.

The healthcare industry is currently using SCRIPT Standard version 10.6 which contains thirteen different transactional exchanges for ePrescribing functions, including:
• Sending a New Prescription;
• Changes to a Prescription;
• Renewals and Resupply Exchanges;
• Cancellation of a Prescription;
• Fill Status Notifications;
• Medication History; and
• Census Exchanges.

Most of these transactions have been named in the regulations associated with the Medicare Modernization Act. While the electronic exchange of new prescriptions, renewals and medication history have grown exponentially, implementation of other transactions has been very slow.

Other capabilities, including the specific issues raised by Dr. Harper, are also available in the existing standard, underscoring the urgent need to increase awareness and industry-wide adoption of the breadth of functionality afforded by the ePrescribing standards. Among them are:

• Structured and codified sig - promotes greater consistency in specifying directions and for clinical review/analysis. The current version used by the industry contains a 140 byte free text field, along with fields to describe the route, indication, vehicle, site, timing, and duration. The structured and codified sig format present in SCRIPT version 10.6 was not intended to support 100% of sigs; however a pilot found that 95% of the fully parsed sig strings were accommodated by the format. Enhancements incorporated in SCRIPT version 2012+ include a more robust Structured Sig Segment which supports a text field size of 1000, as well as other enhancements, recommendations and clarifications from the pilot.
• Support for patient observations - allows prescribers to supply Patient Height, Weight, Diastolic and Systolic Blood Pressure. Patient Weight is useful for validating proper pediatric dosing. Based on questions posed by a Council on Clinical Information Technology Executive Committee article, recommendations for pediatric prescriptions were included in the SCRIPT Implementation Recommendations document publicly available for implementers at http://www.ncpdp.org/Resources/ePrescribing under NCPDP Resources. A challenge is for the prescribing systems to send this information. Enhancements for more observation measurements were included in a more recent version.
• Support for scheduled medications - provides fields necessary to enable ePrescribing of controlled substances.
• Compound prescription support - approved in SCRIPT version 10.8 when industry champions came forward to analyze the needs and work through the requirements.
• Adverse events/reactions - the NCPDP SCRIPT Standard supports the exchange of drug use review (DUR) fields. The industry is actively exploring adding the use of adverse events/reactions/etc., which is used in other transactions, for the use in the ePrescribing transactions via the NCPDP WG11 ePrescribing Best Practices Task Group.
• Support for prior authorizations – provides the means to exchange information needed in prior authorization (PA) requirements, including access to information on covered medications at the point of care, information on PA approvals and denials. The ePA transactions were added in a more recent version that industry participants are actively implementing.

Moving the Needle on Adoption and Implementation of ePrescribing Standards
ePrescribing standards have been enhanced based on requests by the industry which has opted to build functionality in layers. For example, the SCRIPT Standard version 10.6 was published in 2008, with enhancements that are approved and published at least twice a year. But publication is one action; implementation is another. So the question is: How do we move the needle to increase adoption and implementation of the ePrescribing standards?

1. Technology/System Vendors Can Take the Lead or Wait for a Mandate - There are many demands on industry vendors for impact analysis, development, implementation, testing and distribution. Then there is coordination of both prescribing and pharmacy systems implementation, and all within regulatory requirements. In an effort to build a predictable, repeatable process, the industry will be examining if a cyclical implementation timeframe could be adopted to move versions in a more timely and expected manner. In the absence of a mandate, uptake on adoption and implementation depends on technology vendor priorities.

2. Share Lessons Learned to Improve Implementation Guidance – Implementation can be slow when you are blazing new trails. The data itself is complex. It may be pulled from data that is not discrete or doesn’t use the same nomenclature or requires the use of an unfamiliar vocabulary. The electronic exchange can be complicated. It forces analysis of manual workflows. Trading partners may be at different stages of implementation maturity. Benefits are seen from different perspectives. Industry experience in the use of the functionality available is needed, with lessons learned to improve future implementation. NCPDP has active task groups including ePrescribing Best Practices Task Group, Implementation of Structured and Codified Sig Task Group, and many others that are open to materially interested parties to come together in consensus to develop industry guidance, implementation guidance, and future enhancements to the standards.

The complex but vital enhancements to industry standards are developed by the dedicated volunteers across the healthcare industry who share questions, findings, and recommendations. NCPDP, the standards development organization, provides the forum for this important work. See http://www.ncpdp.org/Resources/ePrescribing for more information, including how to get involved.

Unity Farm Journal - 4th week of July 2014

Just as running a winery isn’t all romance, art, and elegance, running a farm is not all romping with your animals, a joyful harvest, and making a profit from the fruits of your labor.

Farming is hard work year round, during the hot humid days of summer, the wet days of Spring/Fall and the chill of winter.  There’s always maintenance and always unexpected tasks.

Some of my farm related posts gloss over the details of day to day operations.  This week, I’ll give you a taste of the kinds of things that require attention.

Our 1.5 miles of trails, our mushroom operations, and manure management all depend on the Terex Front Loader, at PT-30.   Last week, it began leaking hydraulic fluid (basically 30W oil) so rapidly that the roadways are covered with oil stains and the hydraulic fluid tank level is in the red zone.   I crawled under the front loader and found that fluid was dripping from the lowest point of the protective under carriage pan - clearly a hose had come loose or an o-ring had flattened.  The Terex weights 3000 pounds and I have no way of lifting it to remove the protective plates and do an inspection.   Thus we needed to arrange a truck to take it to a service center.   I used a pressure washer to remove some of the driveway oil stains but it has not worked very well.   I'm trying a variety of detergents to loosen the oil from the asphalt, but no magic bullet thus far.

We have an eXMark Turf Tracer mower to manage our acres of pasture and fields.    Many of these areas have not been consistently trimmed in the past and under the 2 foot tall grasses were hidden rocks, logs, and other debris.    The very powerful mower uses a hydraulic power take off to turn the blades.   The debris was simply chopped up - yes the mower cut off the tops of rocks.    Although the end result of all my summer mowing has been beautiful trails and pastures, the mower blades were severely worn.   I had to lift the 550 pound mower, unbolt the blades, and sharpen them with a grinder - it’s all part of standard farm maintenance.   Now that everything is trimmed I’ve removed all rocks and debris so the blades should not be abused again.

Our new baby alpaca, Sunny, is growing up.   She’s learned how to take a dust bath, how to use the alpaca designated poop piles, and how to munch the romaine lettuce from our hoop house that we give the animals every night.    The vet called to say that her IgG measured low the day after her birth.   Like humans, Alpaca get their first antibodies from mother’s milk since they do not pass the placenta.   Sunny was a little slow to start eating, so she was delayed in getting these antibodies.  The vet recommended we monitor her temperature daily for early detection of any infection.    The normal body temperature of a baby alpaca is 101.5-102.5.   Anything greater than 103 is a fever.    Every night for the past week, Kathy and I have taken her rectal temperature.   It’s generally about 101.8, no fever.   Imagine the fun of corralling a 20 pound with the personality of a 2 year old for daily temperature taking!

Of the 3 guinea nests in the forest, one is now abandoned.   Raccoons ate the majority of the eggs and we candled the remainder to discover they were non-viable.   Mom now spends the night safely in the coop.   The other 2 nests were poorly managed - guineas are terrible parents.   I used straw to build warm, self contained incubation areas and now the guineas at least have a chance of hatching their young.    The ducks continue to incubate 9 guinea eggs that the guineas had abandoned.

One of the oyster mushroom areas finished its 3 month spawn run and my task last weekend was to remove 2000 pounds of poplar logs from the black plastic trash bags that served as incubators/humidfiers for the wood and spawn.   We now have about 10,000 pounds of poplar in production for oyster mushrooms and look forward to a major Fall harvest.

We continue to maintain the bee hives.   We spun 9 full frames of perfect summer honey (mostly clover) late one night last week by the light of a lantern.   We’ve used the hot summer days to melt bees wax in our solar melter and at this point we have 10 pounds of wax for votive candle making when then weather turns old and we focus on indoor tasks.

Although the weekend was filled with needed maintenance, there was a bit of joyful harvest.   We  picked over 100 pounds of cucumbers and are using our own cider vinegar to make sweet/hot pickles. We also picked 50 pounds of zucchini, japanese pumpkin, peas, beans, and tomatoes.   This weekend we’ll harvest the carrots, eggplant, and kale.

The next week will be more harvesting, more pickle making, more bee work, more animal care, and planning for our fall crops.    There is no rest for a farmer during the glorious weather of mid summer.

Patient Generated Data Goes Mainstream

Since 1999, Patientsite, the BIDMC  shared record between doctor and patient,  has enabled patients to track blood pressure, glucometer readings, activities of daily living, mood, pain etc. but few patients have used those features.

Why?  Because it requires time and energy to maintain that data.

What if data gathering was entirely passive?

Today, I own a Withings bathroom scale and Withings Pulse O2 wearable monitor.    When I get up each morning, my weight, body mass index, and fat percentage is measured by my scale and wirelessly sent to the Withings cloud where it is routed to my Microsoft HealthVault account and my iPhone Withings app.

As I go through each day, my Pulse O2 device tracks my sleep pattern, my activity level (distance and elevation), my heart rate, and my pulse ox measurement.    Using Bluetooth Low Energy (BTLE), all the data is instantly synched to my iPhone and viewable by hour, by day and by week.

There is nothing I have to do.   All of this just happens as part of my activities of daily living.

There are three factors that are combining to create a perfect storm for patient generated data to enter the mainstream

1.  The devices, standards (content, vocabulary, transport), and usability are good enough.  The total expense of acquiring/using them is cheap enough

2.  ACOs are beginning to accept the fact that home care devices such as pulse oximeters, blood pressure cuffs, electronic  scales, glucometers, and sleep monitors will be essential to care delivery between episodic visits with clinicians.

3.  It’s likely that Meaningful Use and other government programs will offer stimulus (or penalties for non-compliance) for incorporation of patient generated data into the electronic health record.

Every year I take on a personal project and do my best to roll it out in production.  In the past that has included administrative simplification, healthcare information exchange, patient/family engagement, Google Glass, mobile support for our consumer/clinician facing applications, shared care plan creation etc.

Patient generated healthcare data is the next key frontier in care coordination, population health, and clinical research.  Although Beth Israel Deaconess has invested significantly in home care, care management, and telemedicine, it has not yet made the commitment to be a leader in patient generated healthcare data.

I’ve used the pulse oximeter on Mt. Fuji to track my performance and I’ve learned that I walk an average of 20,000 steps per day during my life as a healthcare CIO and farmer.   I’ve learned that sleep pattern is instant deep sleep for an hour, punctuated by light sleep/deep sleep intervals for 30 minutes, followed by waking in 4 hours.    I’ve watched variation of my weight - weekends have more activity and less time eating, so by Sunday night I’m at the lowest point of the week.   During the weekday meetings and office time, I eat more and exercise less.    The good news is that over the course of each month, my weight peaks and troughs cancel each other.

For the next year I’ll be exploring patient generated data, both in devices I use myself, and in the creation of novel applications that enable such data to be incorporated in ACO and clinician workflow without creating data overload for any stakeholder.

I’ll document all my lessons learned along the journey.

Limitations of e-Prescribing Standards

The following is an important guest post from Dr. Marvin Harper, CMIO at Boston Children's Hospital, identifying a gap in e-prescribing standards:

Why am I guest writing a blog post here?   As a practicing pediatrician and CMIO at Boston Children’s Hospital I am particularly sensitive to specific limitations of current e-prescribing standards.

Being able to write and route prescriptions electronically provides many advantages over the handwritten paper prescription process that inherently uses families as couriers.  Nonetheless the current standards for e-prescribing have created a void that permits limitations in certified vendor software on both the prescribing and pharmacy receiving side. The result is that our patients are not yet benefiting from the full potential of eprescribing. Additional national standards for electronic prescription transmission are needed to provide the common ground needed by software vendors at each stage of the prescription life cycle.

The core elements to consider when writing a prescription are the name of the medication, the dose form (e.g., capsules, tablets, extended release tablets, liquids), the amount of medication the patient should take at each dose, the dose frequency (e.g., once, twice or three times per day) and the duration of time for the patient to take this medication.

Currently there are no standards for provision, transmission, receipt or display of weight within electronic prescriptions. To prescribe the correct quantity per dose of the desired medication the weight based dose is converted to a finite dose using a recent, appropriate, and reliable patient weight.  This is then converted to an appropriate drug volume dose (e.g., one tablet, five milliliters) based on the drug product selected (e.g. amoxicillin 500 mg capsule or amoxicillin 250 mg/5 mL suspension).  Considering all of these manipulations, it is then obvious that in order for a pharmacist to review and verify that the correct dose is being dispensed, in addition to the medication and finite dose, the pharmacist needs to have the prescriber’s target weight based dose and the patient weight available at the time of review.   Stated another way, providing the weight is not fully sufficient for the pharmacist to verify the intended target weight based dose. With today’s standard the pharmacist only gets a volumetric dose  (e.g., 5 mL) which is then inferred into a strength dose (e.g., mg/kg) from the prescribed formulation. It is therefore impossible for a pharmacist to fully verify that prescribed doses are appropriate for their pediatric patients.

The current limitation for the entire prescription sig line within a prescription to be transmitted electronically is 140 characters.  Basically a tweet.  Not close to enough for many prescriptions.  As a result we must continue to provide some prescriptions on paper to the patient.

Many commonly prescribed medications require slowly increasing or decreasing the finite dose. These are commonly referred to as medication titrations or tapers and are therapeutically very important to avoid secondary complications.  It can be complex to transfer this information satisfactorily to patients and the pharmacist in the best of circumstances.  It is impossible with a 140 character limit to the sig.  In my experience within pediatrics this is most problematic for prescribing anticonvulsants, steroids, and immunosuppressive medications.

Did I mention the current limitation for the sig line within a prescription to be transmitted electronically is 140 characters.  Basically a tweet.  Not close to enough.  It is not possible to provide a compounding recipe within 140 characters.  Why do we need to write prescriptions for compounded medications? Not all patients can take medications in the dose forms available domestically from pharmaceutical companies.  As a result some medications must be compounded (typically crushed and mixed with other ingredients).  In pediatrics, compounding is most often required to make the medication available in a liquid form for patients unable to swallow a pill. This may also apply to adults, especially those needing to receive medications via feeding tubes.  Occasionally medications must be compounded for other reasons such as palatability or patient allergies.

As uses of medications expand beyond traditional indications, in order for a pharmacist to truly review and verify a prescription order, in addition to mathematical checking, it is critical for a pharmacist to know what the medication is being used for to ensure that the prescribed dose is within the recommended range for any particular indication.  Different indications often require vastly different doses of a medication.

Access to known allergies the patient may have to medications and increasingly access to patient genetic information relating to drug metabolism or adverse reactions can help assure that patients receive the safest medications and doses.

In summary it is important that additional standards for expected eprescribe capabilities are defined for vendors providing prescription writing software, the transmission of prescriptions and the software utilized by pharmacists receiving prescriptions. Most importantly, in my mind, are capabilities to transmit the weight, target weight based dose and more space for the electronic sig to accommodate information needed for medication tapers and compounding.

Unity Farm Journal - Third Week of July 2014

Although midsummer is a time of harvest, the focus of the past week has been on the birth of our new baby alpaca, Sunny.   Our philosophy at Unity Farm is “living things first” - maintenance, infrastructure, and new projects must wait until all our living things are cared for.

Sunny was born at 5pm on July 15 after an 11 1/2 month gestation.   She weighed 17 pounds at birth and walked in the first 30 minutes.   After an hour she was feeding vigorously and proudly displayed her milk mustache.   Her mother is very attentive and the two spend the day playing, resting, and eating.    Our traveling veterinarian visited the farm on July 16 and declared mom and baby in perfect health.    The placenta was perfectly intact, so we are confident that mom will not have any retained tissue.     In the next few weeks, we’ll have another alpaca birth and Sunny will have a playmate to grow up with.

The guineas continue to sit on their woodland nests.    They generally do a very poor job of keeping the eggs warm, so we’re not expecting many new birds from our four nesting moms.   We gathered 50 eggs from one nest and candled them, finding that 9 were developing and 41 were not.   We gave the 9 to the ducks, which are great parents, to hatch.    The ducks also have the advantage that their nests are inside a protected coop at night.   The guineas in the forest have to contend with raccoons, foxes, and fisher cats.

While maintaining one of our pond pumps, I found a garter snake nest.  She has an interesting choice of companion,  bonding with a power cord.   Clearly she prefers her men long, black, and generally quiet.

This week we harvested 25 pounds of Shitake mushrooms, 25 pounds of cucumbers, multiple types of squash, chinese long beans, and tomatoes.   Dinners have included homemade ramen noodles with fresh vegetables and mushrooms as well as mediterranean style tomato/cucumber salads.    It’s Summer and the living is easy!

The weekend will be filled with cleaning our animal areas,  harvesting vegetables, and spreading wood chips on trails.    I've been wearing a pedometer and the average Unity Farm day takes 10 miles of walking, but it's joyful work.
 

The July meeting of the HIT Standards Committee

The July meeting of the HIT Standards Committee included important discussions of certification for post acute care and behavior health applications, review of data segmentation for privacy,  analysis of provider directory standards, an update on the standards/interoperability framework projects, and a first look at the new subcommittee co-chairs of the Standards Committee.

We started the meeting with a review of attestation data by Jennifer King. Jacob Reider reminded us not to judge the trajectory of the project based on the those who attested early.    The data indicates that the bulk of attestations were completed using just a few vendor products, implying that 2014 certified products from multiple vendors are not yet widely implemented.   I asked if any updates were available about the NPRM to offer more flexibility for stage 2 attestation.   HHS is still reviewing the comments, so there is no specific new information that the NPRM will be finalized and we all should continue our work on existing stage 2 criteria during this last federal quarter of 2014.

We next heard from Larry Wolf about the multi-stakeholder effort to specify certification criteria for long term post acute care and behavioral health .  The motivation for this work is to create interoperability and standardization, bringing LTPAC/BH stakeholders into the same ecosystem as those providers participating in the meaningful use program.   Thus far LTPAC/BH vendors have been very interested in the reputational benefits and possible market share gains available from having certified software.   The workgroup did an amazing job specifying high value certification criteria.

Next we heard from Deven McGraw about advances in standards work for Data Segmentation that enables more granular patient control over healthcare information exchange.   An important motivator for this effort is 42 CFR Part 2 which protects the privacy of substance abuse treatment records.   The workgroup was very practical and presented a multi-phased approach that incrementally improves EHR technology.   The first step would be to add a “lockbox” that receives content that cannot be redistributed without additional consent.   If a patient consents to disclose substance abuse treatment from institution A for transmission to institution B, then institution B cannot share that information with institution C unless the patient is re-consented.   The Standards Committee will review the recommendations and standards for for their implementability.   I hope there are early industry pilots that help us learn how best to implement novel consent and privacy controls.

Next, Dixie Baker presented a Provider Directory standards update.   The committee adopted their recommendations which were - no mature standards for provider directory query exist, ONC should organize pilots of simple RESTful/FHIR approaches,  and the National Provider Identifier database should be considered as a potential infrastructure to host provider Direct addresses.

Next, Steve Posnack presented an update on S&I Framework projects.    He also announced that ONC would be encouraging industry and provider stakeholder groups to develop test procedures so that we do not repeat the experience of Stage 2 - test procedures and scripts that are burdensome and not aligned with real world workflow.

Finally, Jacob Reider reviewed the new subcommittee structure of the HIT Standards Committee including co-chairs.   The co-chair of the steering committee is still a work in process.

A very productive meeting.   I look forward to the work ahead as we focus our attention on standards needed to support Stage 3 of meaningful use focusing on fewer use cases in greater depth.

A New Arrival at Unity Farm

Today at 5pm,  our first baby alpaca was born at Unity Farm.   She's 17 pounds and her name is Sunny.    She's eating well and running around the paddock.   The herd is caring for her attentively.

My only role was caring for mom and ensuring the placenta was delivered intact.  Here's a photo of her first steps.

Unity Farm Journal - Second Week of July 2014

I returned from Japan to find that 9 baby guineas (keets) raised by ducks had hatched.   We have one adult white guinea and its genetics seem recessive - of the 100+ keets we’ve hatched there have been no whites.   In this batch, we finally got a white.   Since our one adult white is sitting on a batch of 40 eggs, it’s possible that more whites are on the way.   During the Summer, our guineas build nests and spend the night outside the coop.    At the moment we have 21 guineas roosting in the coop, six sitting on nests, four babies in the mini-coop, and nine in the brooder (pictured below)

Luckily no baby alpaca (cria) arrived during my travels.   I really want to be present to attend their births.   I have just a few days of travel left this Summer.  Let’s hope the alpaca do not pick a travel day!

The hoop house continues to produce an immense amounts of vegetables.    This week we harvested cucumbers which we’ll making in our sweet Unity pickles.

Many flowers are blossoming in the heat of summer, attracting hummingbirds and butterflies, like this painted lady.

The bee hives are continuing to grow during the peak of nectar flow.   We've spun 18 frames of honey and this weekend we hope to spin 9 more.

The animals are thriving, the apples are beginning to fruit, and the meadows are exploding with color.  Even the tree frogs are dropping by for a visit.

Crafting a Next Generation IT strategy

During my 16 years as CIO, I’ve witnessed the transition from client server to web, from desktops to
mobile, and from locally hosted to cloud.  

As Beth Israel Deaconess merges and acquires more hospitals, more practices and more care management capabilities, what are its strategic IT choices?

I will not even mention “best of breed”, because I think the industry has abandoned such a strategy as unworkable in an era when everyone needs access to everything for care coordination, population health, and patient/family engagement.

The choices are basically two

a.  Single monolithic vendor application for everyone everywhere
b.  Best of Suite - the smallest number of applications/modules that meet the need for business integration (defined in the graphic above)

It’s extremely popular among academic medical centers, ACOs, and healthcare systems to choose “A”, often at great cost.

BIDMC has a 30 year tradition of building and buying systems balancing costs, agility, and functionality.

As I plan for the next generation of IT systems, I favor “B” and believe I can achieve our business goals in shorter time, at lower cost, with less risk.

Here’s the thinking.  

1.  At BIDMC, we need a web-based, mobile friendly, cloud hosted solution that has the agility to support rapidly evolving research, education, and clinical requirements.   The culture at BIDMC is not top down, command/control, willing to compromise but bottom up, collaborative, and impatient for innovation.    We will continue to build the core clinical systems at BIDMC until there is a vendor application that meets the cultural requirements and is affordable.

2.  At all other sites, we will use cloud hosted inpatient and ambulatory vendor-based systems that are aligned with the business requirements and culture of the institutions.

3.  Our budgets are very limited to serve 22,000 users and 3000 doctors.  Operating budgets for IT are 1.9% of the total spend.   Capital is about $10 million a year.   One time capital for major IT initiatives is unlikely to ever exceed $20 million.    When I hear about expenditures of hundreds of millions for IT systems, I really wonder how the economics are sustainable.

4.  Interoperability for care coordination across a small number of applications is possible via bidirectional viewing, pushing summaries, and pulling records via the state healthcare information highway.

5.  Business intelligence/analytics across the network is supported by financial and clinical registries, populated via well described interfaces.

Over the next 90 days stakeholders from throughout the organization will complete the next generation IT plan as follows:

July - strategy complete, draft budgets submitted
August - organizational structure for unified enterprise IT proposed, budgets finalized
September - staffing plan finalized and timelines aligned for execution beginning October 1

As with any plan, change management will be the most challenging aspect, balancing time, resources, and scope.

Over the coming months, I’ll share the decisions we’ve made for a cloud of community hospital functionality and a cloud of ambulatory EHR functionality that unifies all our practices.

On Top of Mt. Fuji

July 4 began with a breakfast meeting to discuss cloud computing with Japanese industry leaders.   Japanese industry is ready to provide cloud solutions, but there are policy and adoption barriers including privacy protection, service level guarantees, and general distrust of the internet as a transport mechanism for healthcare data.     To explore these barriers, I visited the Japanese Medical Association for lunch and had a remarkable discussion while walking in the Rikugien Gardens.   I spent the afternoon with policymakers at the Japanese Ministry of Health, Welfare and Labor.    We reviewed the Beth Israel Deaconess clinical systems, Massachusetts eHealth Collaborative Quality Data Center and  the Massachusetts Health Information Highway as examples of private/public collaboration for public health, population health, and care management cloud-based applications.

The meeting ended at 3:30pm I took a taxi to the Shinjuku West Bus Terminal where my Japanese hiking partner (Dr. Nagata) and I exchanged our business suits for hiking gear.   After stashing our computers and luggage in a locker we boarded the Fuji bus carrying water, food (onigiri rice balls), and the appropriate clothing we'd need to climb the 12,376 foot Mt. Fuji in rain, light snow, and freezing temperatures.   I travel internationally with carry on baggage, so I had to be very minimalistic in choosing the hiking gear to bring.

Our plan was to do a "bullet climb" - from the trailhead of the Yoshida trail to the summit of Fuji without stopping to rest/sleep at the mountain huts along the way.    The trail was uncrowded given the bad weather and cold summit of early July.      The trailhead weather was in the high 40's F and raining.    Hiking in warm wet weather in total body Gore-tex is always a clammy experience.    In a few hours, we climbed to 10, 170 feet, the 8th station, without feeling any altitude effects.    As an experiment, we carried a small pulse oximeter and found that at 10,000 feet our oxygen saturation was about 95 with a pulse rate in the 80's.

The trail from the 8th station to the summit becomes much steeper, with loose, wet, volcanic rock.  At this point those hikers who brought running shoes have difficulty traversing the trail.   It's also the point at which the temperature drops and altitude effects become noticeable.    Our goal was a steady pace and we climbed to the 8.5th station, the 9th station, and finally the summit arriving at 2:30am to light snow, 10 mph winds and freezing temperatures.     Since twilight and sunrise viewing would be best 3:30am-4:30am, we decided to sleep a bit on the platforms near the shrine at the summit.    Hiking at freezing temperatures in a base layer and gore-tex is easy, but sleeping is challenging.  We did have mid layers for warmth which we added as our bodies cooled down.    While at rest our oxygen saturation varied from 88 to 92 with a pulse of about 100.  

We were the first hikers on the summit that morning and we watched the line of headlamps snaking up the mountain from our summit perch.

Between 4am-4:30am, the clouds parted and we saw the sunrise - the rising sun from the highest point in the land of the rising sun.

After sunrise we explored the crater of Mt. Fuji and then began our descent through the large Torii gate at the summit.   We walked through thick cloud cover and pouring rain, arriving back at the trailhead by 8am.     In retrospect, I had a 24 hour day that began and ended with a discussion of "clouds" in Japan.

Unity Farm Journal - First week of July 2014

While I’m in Japan, Kathy has her hands full at Unity Farm.   I did my best to prepare the farm for my 5 days away including building bee hive supplies, ensuring the health of all the animals, and completing all the monthly maintenance tasks.

As I’ve posted before, Guinea fowl are horrible parents.  They lay eggs in a communal pile then assign a designated layer to incubate them.  When the eggs hatch the young have to find their way to the coop, often through tall wet grass and through predator laden terrain.   Most don’t make it.   This year, we’re helping them a bit.

The ducks hatched 4 guineas and kept the babies (keets) warm and safe in a brooder for 2 weeks before moving them into the coop.   It’s likely the adults would attack them if they ran free in the barnyard, so we had to build a protected enclosure - a coop within a coop.  I call it the mini-cooper (sounds like a catchy name).   Here’s a photo of the keets enjoying their new coop space, safe from the adults.

The ducks have been sitting on another 17 eggs and we moved them from the duck house to the incubator before I left to prevent Kathy’s having to keep newly hatched birds from drowning in the duck pond (Guineas can’t swim).

At the moment, we have two large nests on the farm - one to the north near the hoop house with about 40 eggs and another to the south with about 30 eggs.   Two designed female guineas keep the eggs warm all night and thus far have not been attacked by nighttime predators.   The keets should hatch July 18, so we’ll be on the lookout and rescue them if needed.    We have 30 guineas today (and could accommodate 50),  Every summer we lose some to predators, so the new additions are likely to keep the population stable.

Over the weekend we weighed, immunized, and examined every animal in the farm.  Two of the alpaca are pregnant (Mint and Persia).   Their abdomens are round and their breasts are filling with milk.   We believe they will deliver in the next 30 days after an 11 1/2 month gestation.   Baby alpaca are called cria and these will be the first new alpaca born on the farm.   Every day is a cria watch.  I really hope they do not deliver while I’m in Japan.

Belle, the duck with the injured eye is healing fast and after 3 weeks of antibiotics, she has returned to her daily duck activities - swimming in the pond, hunting for insects, and nest building with her comrades.

We inspected the bee hives and added queens to two of them, given that lack of eggs in the brood boxes that implies the old queens have died.   Normally, the bees would have made “emergency queens” by feeding royal jelly to a developing bee, but in this case, there were no queen cells in the hives, implying that the queen’s death must have been rapid and unexpected.

Shiro, our 125 pound male Great Pyrenees, turned 2 years old this week.     When he was born, a blue ribbon was placed around his neck.    Today he wears a blue collar.   Here are “before” and “after” pictures.

Next weekend I'll be hauling logs and cleaning up any debris for the hurricane that is on track to hit the East Cost on Friday.

Dispatch from Tokyo

I’m in Japan today lecturing at the TOPOS Conference. per the request of several colleagues.  Think of it as TED in Tokyo.    I’ve been asked to discuss the Meaning of Life in an Aging Society without referencing Healthcare IT, which is a real challenge for a CIO.

The approach I’ve taken is to explore life through the eyes of those in my family - my father who passed away last March, my mother, my wife and my daughter.   I’m reviewing our experiences together and the impact they’ve had on my life, while recounting what is meaningful to them.   Here’s the powerpoint I’m using.

Tomorrow will be a day of meetings with government, academic, and industry leaders to discuss the use of cloud computing in Japanese healthcare.   Although there have been examples of cloud computing used after 3/11 (the great Tohoku earthquake, tsunami, and Fukushima nuclear plant destruction) there is still great distrust of the cloud.    The internet in Japan is considered a swamp of malware and bad actors, which it is.  However, there are technologies and policies that can ensure the data integrity and privacy of patient identified data.

Japan does not need more locally installed large servers, it needs a cloud of low cost commodity servers distributed geographically such that any natural event will not cause data loss or disruption.

After my meetings, I will climb Mt. Fuji over night, with the hope of watching the sunrise from 12,500 feet - the rising sun in the land of the rising sun.   The mountain opens for hiking on July 1, so early July is generally the time less traveled.   There will be subfreezing temperatures and light snow at the top, but 70F temperatures at the bottom.   I’ve already told my hiking partner, a professor from Kyushu University, that summiting is optional.   Returning to Tokyo is mandatory.

Wish me luck.